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BACKGROUND: The Public Access Defibrillation (PAD) Trial was a randomized, controlled trial designed to measure survival to hospital discharge following out-of-hospital cardiac arrest (OOH-CA) in community facilities trained and equipped to provide PAD, compared with community facilities trained to provide cardiopulmonary resuscitation (CPR) without any capacity for defibrillation. OBJECTIVES: To report the implementation of community-based lay responder emergency response programs in 1,260 participating facilities recruited for the PAD Trial in the United States and Canada. METHODS: This was a descriptive study of the characteristics of participating facilities, volunteers, and automated external defibrillator (AED) placements compiled by the PAD Trial, and a qualitative study of factors that facilitated or impeded implementation of emergency lay responder programs using focus groups of PAD Trial site coordinators. RESULTS: The PAD Trial enrolled 1,260 community facilities (14.8% residential), with 20,400 lay volunteers (mean +/- standard deviation = 13.4 +/- 10.7 per facility) trained to respond to OOH-CA. The 598 locations randomized to receive AEDs required 2.7 +/- 1.8 AEDs per facility. Volunteer attrition was high, 36% after two years. Barriers to recruitment and implementation included identification of appropriate "at-risk" facilities, lack of interest or fear of litigation by a facility key decision maker, lack of motivated potential volunteer responders, training and retraining resource requirements, and lack of an existing communication/response infrastructure. CONCLUSIONS: These data indicate that implementation of community-based lay responder programs is feasible in many types of facilities, although these programs require substantial resources and commitment, and many barriers to implementation of effective PAD programs exist.

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OBJECTIVES: To examine trends in paramedic rhythm misidentification rates in the use of adenosine for presumed paroxysmal supraventricular tachycardia (PSVT) over a ten-year period, and to determine variables associated with rhythm misidentification. METHODS: The authors conducted a retrospective analysis of all cases in which paramedics treated presumed PSVT with adenosine from 1993 to 2002. Rhythm strips were categorized as narrow or wide-complex and regular or irregular. Appropriate use of adenosine was defined as narrow-complex regular tachycardia with no visible P waves and rate greater than 140 beats/min. RESULTS: The authors studied 224 patients with a mean age of 60 years (range, 15-94 years); 157 (70%) were female and predominantly white. The majority (54%) of patients had initial heart rates of 161-200 beats/min. Forty-nine percent of the patients had a previous history of PSVT. Inappropriate use of adenosine occurred in 45 (20%) cases. Misidentification rates per year ranged from 9% to 31% with the lowest rate occurring after a targeted education program on tachydysrhythmias. An initial heart rate of <160 beats/min (chi(2)=14.81, p<0.001) and absence of a medical history of either fast heart rate or palpitations (chi(2)=11.35, p=0.001) were associated with inappropriate use of adenosine. CONCLUSION: Paramedics in this emergency medical services system are more likely to use adenosine appropriately for patients with initial heart rates of >160 beats/min and a history of rapid heart rate or palpitations. Further studies are required to identify factors associated with rhythm interpretation errors in the prehospital setting as well as to evaluate error reduction strategies.

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OBJECTIVE: To assess public views on emergency exception to informed consent in resuscitation research, public awareness of such studies, and effective methods of community consultation and public notification. METHODS: A face-to-face survey was conducted in two academic Level I trauma center emergency departments (EDs) in Oregon and Minnesota from June through August 2001. RESULTS: Five hundred thirty people completed the survey, with an 82% response rate. The mean age of the respondents was 41 years (range 18-95) with a standard deviation of 14.5; 46% were female and 64% white. Most (88%) believed that research subjects should be informed prior to being enrolled, while 49% believed enrolling patients without prior consent in an emergency situation would be acceptable and 70% (369) would not object to be entered into such a study without providing prospective informed consent. Informing and consulting the community as a substitute for patient consent in emergency research was thought to be reasonable by 45% of the respondents. Most respondents would prefer to be informed about a study using emergency exception from informed consent by radio and television media (42%). Two hundred fifty-eight respondents (49%) stated they would attend a community meeting; the less educated were more likely to attend than those with college degrees (OR = 0.53; 95% CI = 0.33 to 0.85, p = 0.008). However, only 5% knew of ongoing studies in their community using emergency exception from informed consent. CONCLUSIONS: Most respondents disagreed with foregoing prospective informed consent for research participation even in emergency situations; however, many would be willing to participate in studies using emergency exception from informed consent. Most respondents would not attend community meetings, and would prefer to rely upon the media for information. Very few were aware of emergency exception from informed consent studies in their community. This suggests that current methods of community notification may not be effective.

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OBJECTIVE: To determine whether Advanced Trauma Life Support (ATLS) practices characterizing initial resuscitation and interfacility transfer at rural trauma hospitals are associated with risk-adjusted survival. METHODS: Retrospective, observational analysis of rural injured patient survival. Process-of-care variables were associated with TRISS (trauma and injury severity score)-derived Z-statistics (95% confidence intervals) for high-risk population subsets (defined below). INCLUSION CRITERIA: all patients > or = 12 years of age entered into a statewide trauma system, January 1, 1995, to December 31, 1999, and initially presenting to Level III trauma centers (N = 4,961). EXCLUSION CRITERIA: pronounced dead on arrival (n = 26), directly admitted to hospital (n = 3), and unknown disposition at first hospital (n = 2). Process variables include: intubation in emergency department (ED) given Glasgow Coma Scale (GCS) score < 9 [INTUB], administration of blood products in ED given systolic blood pressure (SBP) < 90 mm Hg [BLOOD], trauma surgeon presence within 5 minutes of patient arrival given GCS < 9 mm Hg or SBP < 90 mm Hg [UNSTABLE-TS], trauma surgeon presence within 5 minutes of patient arrival given injury severity score (ISS) > 15 [ISS-TS], transfer to higher level of care given ISS > 20 and no hypotension [TRAN], transfer to higher level of care given GCS < 9 [TRAN-GCS]. RESULTS: For the high-risk subpopulations, the following Z-scores (with and without an intervention) were found: CONCLUSIONS: Some ATLS interventions (BLOOD, TRAN, and TRAN-GCS) are associated with improved survival for selected high-risk subgroups in these 21 rural Level III trauma hospitals.

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